a nurse is caring for a client using o2 while in the hospital what assessment finding indicates that goals for a priority diagnosis are being met a nurse is caring for a client using o2 while in the hospital what assessment finding indicates that goals for a priority diagnosis are being met
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

2. Malnutrition continues to be a public health concern in the country. The common nutritional deficiencies are the following, except:

Correct answer: D

Rationale: The question addresses common nutritional deficiencies, except for one. Vitamin A, Iron, and Iodine are often cited as common deficiencies in populations facing malnutrition. However, Calcium deficiency is not typically considered one of the common nutritional deficiencies in such contexts. Calcium deficiency can occur but is not as prevalent as the other options listed in populations with malnutrition.

3. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?

Correct answer: B

Rationale: A lithium level of 1.7 mEq/L is above the therapeutic range, indicating a potential risk of toxicity. The initial nursing intervention should be to instruct the patient to hold the next dose of medication and promptly contact the prescriber for further guidance and management. This action aims to prevent adverse effects and ensure the patient's safety by addressing the elevated lithium level appropriately.

4. The nurse is caring for an infant who was born 24 hr ago to a mother who received no prenatal care. The infant is a poor feeder but sucks avidly on his hands. Clinical manifestations also include hyperactive reflexes, tremors, sneezing, and a high-pitched shrill cry. What does the nurse consider as a possible diagnosis for this infant?

Correct answer: B

Rationale: In this case, the infant's symptoms are consistent with narcotic withdrawal. Infants exposed to drugs in utero may display withdrawal symptoms starting around 12 to 24 hours post-birth. The presentation often includes hyperactive reflexes, tremors, sneezing, high-pitched shrill cry, poor feeding, and sucking avidly on hands. Signs such as loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating are common. These symptoms are not indicative of a seizure disorder. Placental insufficiency typically leads to a small-for-gestational-age child, which is not mentioned in the scenario. Meconium aspiration syndrome primarily presents with respiratory distress, not the symptoms described in this case.

5. When providing dietary teaching for a new prescription of phenelzine, which of the following foods should be avoided?

Correct answer: A

Rationale: The correct answer is A, Broccoli. Foods high in tyramine, such as broccoli, should be avoided when taking MAOIs like phenelzine to prevent a hypertensive crisis. Yogurt, cream cheese, and fruit juice do not contain significant levels of tyramine and can be safely consumed while on phenelzine.

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